The High School Athlete: Setting Up A High School Sports Medicine Program


We would like to acknowledge Dr. Stephen G. Rice for his contributions to prior versions of this chapter.

General Principles

Athletic Healthcare in High-Level Collegiate and Professional Sports

  • At the highest levels of sports, organizations are much like corporations; they function to increase success of shareholders by providing a product (i.e., winning team) linked to profitability.

  • Although there are ethical concerns with this model, it provides an environment of highly established care because the athlete’s health is linked to the team’s success.

  • The characteristics of such models include:

    • Remarkable financial resources

    • Well-defined roles and responsibilities

    • Risk management and loss control

    • Optimization of athletes’ health for on-field performance

    • High organizational control and attention to detail

    • Professional personnel secured in adequate quantity

    • Certified athletic trainers (ATCs)

    • Qualified team physicians (sports medicine fellowship-trained primary care physicians, and orthopaedic surgeons)

    • Other allied healthcare professionals, including certified strength and conditioning coaches, nutritionists, psychologists, optometrists, dentists, exercise physiologists, and physical therapists (PTs)

  • Compliance with Team Physician Consensus Statement (see Recommended Readings)

  • Policies delineated and enforced routinely

Differences in Athletic Healthcare for the High School Athlete

  • The effect of high-profile professional and collegiate sports has trickled down into secondary schools, with many school administrators, coaches, and parents looking for the same type of on-demand medical care

  • However, most schools have the following concerns:

    • Lack of financial resources

    • Lack of leadership—just maintain status quo

    • Turnover of personnel (school board, superintendent, principal, athletic directors [ADs], and coaches)

    • Not a priority—too many other issues

    • Lack of medical resources

    • No ATC or team physician

    • Inadequate medical knowledge among coaches and ADs

    • Inadequate communication within the medical community

    • Results in incorrect or delayed care

    • Lack of consistent policies/standards

    • No overall single system of care at a school—each coach does his or her own thing

    • Each school may be different within a district

    • Assumed to be met by minimal standards and effort by external personnel or agencies, such as state-required preparticipation physical evaluations (PPPEs), volunteer team physicians, or presence of an ambulance

Solution: Goals and Requirements

  • Goals: appropriate healthcare for athletes and minimal liability through a risk management (loss control) policy

  • Requirements: knowledge, organization, and commitment toward detailed planning

Approach to Optimal High School Athletic Healthcare

Key Elements

Four key elements of the approach: family, school, medical community, and ATCs

Family Involvement

  • Most high school athletes are minors and are dependent on their parent(s) or guardian(s)

  • School, ATC, and physician must focus on communication with parents/guardians of injured athletes because parents/guardians:

    • Know the athlete’s medical history

    • Are often more concerned with their children’s health and academics than sport

    • Are important resources regarding psychosocial dynamics

  • Financial concerns may prevent seeking appropriate care

School Commitment

  • School should assume responsibility for operating safe programs

    • Obligations toward students and their families; commitment to meeting them; solutions must be internal as well as external

    • Qualifications and backgrounds of ADs and coaches

    • Should work as a unit, operating a single interscholastic athletic program and single athletic healthcare program

    • Institution of policies, guidelines, and procedures for daily use

    • Record-keeping system

    • Emergency action planning (EAP) and first-aid/cardiopulmonary resuscitation (CPR) training

  • Seek assistance from the medical community for all sports: PPPEs as well as preseason fitness screening, weekly school visits, event coverage, therapies and treatments

    • Know what is desired from physicians, PTs, and clinicians

    • Designate team physician(s)

  • Hire National Athletic Trainers’ Association (NATA)–certified ATCs (state licensed if applicable), as they are the most suitable professionals to coordinate and operate the athletic healthcare program

    • Cannot be present simultaneously at all athletic venues

    • Use of student athletic trainers and educated coaches for assistance

    • Requires a support system

    • Policies and procedures, including record-keeping, accountability, and quality assurance systems

  • Requires wireless communication and golf cart to meet obligations of daily coverage and emergency response

  • Should insist on medical supervision and quality assurance system

  • Should have an adequate budget

  • Reasonable schedule demands

    • Known high turnover rate for ATCs due to heavy workload

    • Consider second ATC in large high schools

Medical Involvement (Team Physicians)

  • A written contract is best

    • Delineates responsibilities and expectations

    • Helps ensure that the school has given careful thought to its obligations

    • Good communication leads to good working relationships

  • Monetary compensation—yes or no?

    • Compensation may nullify “Good Samaritan” immunity

    • Amount offered is frequently meager compared with earnings in office

    • True value of assistance provided?

  • Responsibilities (enumerated in Team Physician Consensus Statement)

  • Jurisdiction: Are your decisions final?

  • Medicolegal (liability) concerns

    • Good Samaritan law immunity may cover team physician in certain states

    • Team physician may not qualify as a Good Samaritan under strict definition—“someone without obligation who steps forward to render emergency care”

    • Has clearly defined responsibilities toward athletes, school, and athletic program

    • Event coverage is evidence of that responsibility

    • May be covered by “good intent, no compensation” concern

    • Good Samaritan immunity extends only to “emergency care” rendered during event coverage; protection does not extend to PPPEs, weekly injury clinics at school, and return-to-play (RTP) clearance evaluations

    • Potential responsibility and liability for ATC’s actions

    • Need to clarify issue with school district

    • ATCs generally function “under direct medical supervision of a physician”

    • In states that have not specifically defined the “scope of practice” for ATCs through licensure, certification, or registration:

    • Team physician needs to assess implications and responsibilities of “direct medical supervision”

    • Analogous supervisory situation may be the physician–physician assistant relationship

    • Written standing orders for ATC and EAPs are essential for limiting any liability risks

    • Malpractice insurance and liability coverage

    • Incorporated into your personal or clinic policy (already existing or a new rider clause to be added)

    • Through school district insurance policy

  • Medical privacy concerns (HIPAA and FERPA)

    • Health Insurance Portability and Accountability Act (HIPAA) of 1996 and Family Education Rights and Privacy Act (FERPA) in 1974 were developed to regulate “protected health information” (PHI)

    • FERPA regulations prevail within domain of public schools, including school nurses, school physicians, coaches, and ATCs

    • HIPAA Privacy Rule allows release of medical information without authorization for “treatment, consulting with other providers, referring the patient to other providers, and notifying a patient’s family”

    • Athletes who consult at medical facilities outside of school will most likely fall under purview of HIPAA

    • Eligibility decisions regarding “cleared” or “not cleared” on PPPEs can be provided to coaches and school administrators (without inclusion of other medical information) without signed consent

    • For group PPPEs conducted at the school, must ensure confidential storage of forms, with PHI pertaining to restrictions shared only with those who have “need to know”

    • Need to know—always includes ATC, school nurse, and team physician

    • Variable for coach and administration depending on circumstances because the athlete’s well-being may require one to understand his or her limitations or signs and symptoms

    • Coaches and administrators, as well as school nurses and ATCs, must be made aware of FERPA and HIPAA regulations and constraints regarding privacy of PHI

  • Degree of involvement

    • Set overall medical policy with AD and ATC

    • Strongly consider forming a medical advisory board with school district

    • Provide medical advice to interscholastic athletic program

    • Provide medical coverage at games. Ideal goal—to see every team member at least once during the season—may require division of coverage among several physicians, possibly by sport or on a rotational basis

    • Football team: home varsity coverage (mandatory); away varsity and home subvarsity coverage (recommended)

    • Wrestling team: preseason weight class recommendations, midseason weight certification, assessment of skin for communicable diseases, and coverage of home matches (recommended)

    • Coverage of all tournaments at home school

    • Soccer team (boys and girls): coverage of events as schedule permits

    • Basketball team (boys and girls): coverage of events as schedule permits

    • Other sports as schedule permits with attention to contact or collision sports

    • Develop an emergency contacts list and EAP, including use of automated external defibrillator (AED) for sudden cardiac arrest

    • Develop a concussion action plan, including return to academics and sport

    • Conduct PPPEs

    • Visit school/athletes regularly

    • Educate coaches and ATCs

    • Provide support for ATC’s authority

    • Medicolegal supervisor of the ATC

    • Assess knowledge, skills, and experience of the ATC and mutually develop an appropriate set of standing orders with cumulative working relationship and legal scope of practice for ATCs in their jurisdiction

    • Role in creating a job description, interviewing, and hiring

    • Role in job evaluation

    • Role in quality assurance of care rendered by ATC

    • Frequent and regular communication

    • Chart review and case studies as needed

  • Role of a team physician in school without an ATC

    • Understand history and culture of the school

    • Assess strengths and weaknesses of how athletic care is and was provided

    • Greater challenge to meet responsibilities

    • Possible institution of athletic healthcare system (AHCS; see the following section)

    • Encourage school to recognize need for ATC

  • Role of a new team physician in school with established ATC

    • The team physician should understand the methods and culture of the existing system.

    • ATC may welcome an active, involved, “hands-on” team physician or prefer a more distant consultant model if he or she is comfortable as the central focus of the AHCS and confident of his or her abilities and skills.

    • Team physician should develop an appropriate relationship with ATC.

Athletic Trainer

  • Hiring considerations and working conditions (team physician should help school in the hiring process)

  • Funding is a factor—ATC often low-paying, entry-level job

  • If ATC is hired, under what conditions?

    • Full- or part-time ATC?

    • Teacher and ATC? How many classes?

    • How many working hours per week, including games?

    • How many working days per year?

    • ATC needs more days than regular school calendar

    • If general contract calls for same number of days as teachers, it must account for preseason football days, weekends, and holiday tournament days

    • Possible solution: part-time substitute ATC, who works 1 day per week throughout school year (40 days); this schedule decreases the risk of burnout for full-time ATC (from not having time off) and allows ATC to work same number of days as teachers

    • Part-time ATC can service several schools each week, if more work is desired

  • Medical backup and supervision

    • Head team physician should be specifically recognized as the medical supervisor of the ATC

    • Degree and frequency of communication should be clearly established

    • Whose decision is final regarding RTP?

  • Adequate budget for equipment and supplies, professional fees, books, and continuing education

  • Quality of training room

  • Written job description

  • Job performance (accountability and quality assurance)

    • Evaluated by team physician and others (e.g., AD, school nurse, coaches, principal, and athletes)

  • Potential for career advancement

Athletic Healthcare System

Generic Model System

  • The AHCS was initially developed by adapting college and professional sports medicine programs to high school level

  • This can be installed at any school, large or small, and at any school location, rural or urban

  • The AHCS should be tailored to each school and adhere to accepted standards of practice

    • Effectiveness of the AHCS is greatly improved with an ATC and a sports medicine–trained team physician

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